Aortic regurgitation — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 63-year-old woman (BSA 1.6 m²) with a bicuspid aortic valve is referred after a murmur is heard. She reports no symptoms. Echocardiography shows a vena contracta of 0.7 cm, regurgitant volume 62 mL/beat, regurgitant fraction 51%, ERO 0.32 cm² and a dilated LV.^[2] Her resting LVEF is 58%, LVESD 42 mm and LVESDi 26 mm/m². Her aortic diameters are normal.^[1]

1. Which ACC/AHA 2020 Table 15 stage is she in, and which of her echo findings meet its severe AR criteria? (2)^[2]
2. Give the strongest ESC/EACTS 2025 Recommendation Table 3 row that applies to her, with class and level. (2)^[1]
3. Give the ACC/AHA 2020 timing row that applies, with COR and LOE, and state how the two guidelines grade her differently. (2)^[3][1]
4. What does the ACC/AHA 2020 supportive text say about indexing LVESD? (1)^[3]
5. Which imaging would refine the LV assessment in a borderline case, according to ESC/EACTS 2025? (1)^[1]
6. Which ESC/EACTS 2025 row covers valve repair, with class and level? (2)^[1]

Model answers — SAQ 1

1. Stage C2 on the indexed criterion: Table 15 defines C2 as abnormal LV systolic function with depressed LVEF (≤55%) or severe LV dilation (LVESD >50 mm or indexed LVESD >25 mm/m²), and her indexed LVESD is 26 mm/m² (1 mark).^[2] Her unindexed LVESD of 42 mm lies in the C1 band (LVESD <50 mm), and the ACC/AHA 2020 COR 2a row labels indexed LVESD >25 mm/m² as Stage C2.^[2][3] Severe AR criteria met: vena contracta >0.6 cm, regurgitant volume ≥60 mL/beat, regurgitant fraction ≥50%, ERO ≥0.3 cm², with the required evidence of LV dilation (1 mark).^[2]
2. AV surgery is recommended in asymptomatic patients with severe AR and LVESD >50 mm or LVESDi >25 mm/m² [especially in patients with small body size (BSA <1.68 m²)] or resting LVEF ≤50% (1 mark).^[1] Class I, Level B; her LVESDi of 26 mm/m² meets it, and her BSA of 1.6 m² falls within the "especially ... BSA <1.68 m²" bracket (1 mark).^[1] Her LVESDi also exceeds the 22 mm/m² cut-off of the Class IIb, Level B row (AV surgery may be considered if the surgical risk is low), but the Class I, Level B row is the stronger.^[1]
3. ACC/AHA 2020: in asymptomatic patients with severe AR and normal LV systolic function (LVEF >55%), aortic valve surgery is reasonable when the LV is severely enlarged (LVESD >50 mm or indexed LVESD >25 mm/m²) (Stage C2) (COR 2a, LOE B-NR) (1 mark).^[3] ESC/EACTS 2025 puts LVESDi >25 mm/m² [especially in patients with small body size (BSA <1.68 m²)] in a Class I, Level B row for asymptomatic severe AR, whereas ACC/AHA 2020 puts indexed LVESD >25 mm/m² with LVEF >55% in a COR 2a row; state each by body and year (1 mark).^[1][3]
4. Most studies have used unadjusted LVESD, but indexing for body size is important, particularly in women or small patients (1 mark).^[3]
5. 3D echocardiography and CMR allow more accurate evaluation of LV volumes and LVEF than 2D echocardiography, and are useful in borderline cases (1 mark).^[1]
6. AV repair should be considered in selected patients with severe AR at experienced centres, when durable results are expected (1 mark).^[1] Class IIa, Level B (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 48-year-old man presents with fever and breathlessness. He has infective endocarditis with acute severe aortic regurgitation.^[3] He is hypotensive with pulmonary oedema.^[3]

1. What haemodynamic consequences of acute AR does ACC/AHA 2020 describe? (1)^[3]
2. List four things TTE or TEE establishes in acute AR (ACC/AHA 2020). (2)^[3]
3. What does a pressure half-time of <300 ms on the AR velocity curve indicate, according to ACC/AHA 2020? (1)^[3]
4. What does ACC/AHA 2020 say about medical therapy and the timing of surgery in this patient? (2)^[3]
5. Which mechanical support does ACC/AHA 2020 call contraindicated, and what caution does it give for beta-blockers? (2)^[3]
6. What does ESC/EACTS 2025 say about TAVI in acute AR, and what can temporarily improve haemodynamics until the intervention? (2)^[1]

Model answers — SAQ 2

1. The acute volume overload on the LV usually results in severe pulmonary congestion, as well as a low forward cardiac output (1 mark).^[3]
2. Confirming the presence, severity and aetiology of acute AR; determining whether there is rapid equilibration of the aortic and LV diastolic pressures (1 mark).^[3] Visualising the aortic root; and evaluating LV size and systolic function (1 mark).^[3]
3. ACC/AHA 2020: rapid equilibration of the aortic and LV diastolic pressures (1 mark).^[3]
4. Medical therapy to reduce LV afterload may allow temporary stabilisation (1 mark).^[3] But surgery should not be delayed, especially if there is hypotension, pulmonary oedema or evidence of low flow, as here (1 mark).^[3]
5. ACC/AHA 2020: intra-aortic balloon counterpulsation is contraindicated in acute severe AR (1 mark).^[3] ACC/AHA 2020: beta blockers should be used very cautiously, if at all, for causes of acute AR other than aortic dissection, because they block the compensatory tachycardia and could precipitate a marked reduction in blood pressure (1 mark).^[3]
6. Surgery represents the preferred treatment in acute AR, while TAVI has only been described in individual cases or patients with a failed surgical valve (valve-in-valve) (1 mark).^[1] Fast pacing over a temporary pacemaker lead shortens the diastole and may temporarily improve haemodynamics until the intervention (1 mark).^[1]